BIRTH PALSY

PRESENTED BY:
DR.MANISH BAVISKAR
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INTRODUCTION
• First described clinically in 1779 by Smellie who cited a case of
bilateral arm paralysis following a face presentation, which
resolved in a few days
• Danyau carried out an autopsy on a neonate who died shortly
after traumatic forceps delivery
• Duchenne in 1872 attributed the injury to traction on the arm
and introduced the term obstetric paralysis
• Erb in 1874 discovered that the characteristic paralysis of the
deltoid, biceps, coracobrachialis and brachioradialis could be
caused by disruption of C5 and C6 roots at the point where they
emerge just between the scalene muscles, [which has therefore
been named after him]
• Klumpke in 1885 described the paralysis of the lower roots of
the brachial plexus and highlighted the involvement of the
sympathetic fibres in this paralysis.

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AETIOPATHOGENESIS
• Postulates ranging from
poliomyelitis,congenital lesion,sequelae of
subclinical systemic toxemia,posturla in-utero
ischemia
• Risk factors-shoulder dystocia,maternal
diabetes,Large foetus,Cephalo-pelvic
Disproportion,Difficult labour:breech, face to
pubis,transverse presentations
• Bentzon’s thesis-Erb - Duchenne paralysis always
develops as a sequel to over-stretching of the plexus
by simultaneous lateral flexion of the neck and
contralateral depression of the opposite shoulder.
• more common in multiparous than in primiparous
women.
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CLASSIFICATION
• Classified into
 Upper plexus palsy (Erb’s)-C5,C6,C7
 Lower plexus palsy (Klumpke’s)-C8,T1
 Total plexus palsy
INCIDENCE:
•0.38-1.86/1000 live births
•Risk factors-macrosomia,shoulder dystocia,assisted
delivery,breech delivery,prolonged labour,excessive maternal
weight gain,previous similar family history
•Assoc. injuries-# clavicle,physeal # of humerus,#s about
shoulder girdle,torticollis,facial nerve palsy,Horner’s
syndrome,phrenic nerve palsy
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ETIOLOGY
• Traction forces to fetus in utero on
nervestemporary conduction
deficits,nerve root avulsions from spinal
cord
• Lateral torsion to neck,direct traction to
isolated upper limb
• Compression injuries to umbilical cords
or amniotic bands
• In-utero trauma in bicornuate/fibroid
uterus
• Ceaserian deliveries
• Most common-macrosomic
baby,delivery complicated by shoulder
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PATHOPHYSIOLOGY
• Depending on i.severity of injury
ii.anatomical location
 Upper-most common (73%-86%)
-muscles involved-external
rotators,abductors of shoulder,elbow
flexors,supinators,wrist extensors
(WAITER’S TIP ie.IR,Ad.,Pron.,Palmar
flexion)
 Lower-least common (0.6%)muscles
involved-wrist and finger
flexors,intrinsic hand muscles (CLAW
HAND)
 Total-20%
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-flail,insensate arm
Associated other nerve injuries
• Phrenic nerve(C3-C5)-hemidiaphragmatic
paralysis
• Sympathetic communicating branch to stellate
ganglion-Horner’s syndrome
(ptosis,anhydrosis,myosis,enophthalmos
Grave prognostic sign-Horner’s syndrome,flail
extremity,multiparous mother,weight>4500gms

Glenoid deformities-glenoid hypoplasia,humeral head

flattening,acromial beaking,hooking of coracoid
process,posterior subluxation/dislocation of shoulder joint

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Waters et al classification of glenohumeral
deformity by radiographic type

• I-<50 difference in retroversion

• II->50 difference in retroversion (no posterior
subluxation
• III-posterior subluxation of humeral head
• IV-severe deformity
• V-flattening & dislocation of humeral head &
glenoid
• VI-dislocation of humerus head in infancy
• VII-growth arrest of proximal humeral
epiphysis
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Clinical presentation
• Perinatal history
• Assoc. h/o Horner’s syndrome,ipsilateral
phrenic n. palsy,facial n. palsy
• R/o cervical spine patho.,cerebral
palsy,septic shoulder
• Range of motion-all affected joints
(active/passive)
• Sensory examination
• torticollis-
• Loss of sympathetic tone
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INVESTIGATIONS
• X-RAYS-cervical
spine,shoulder,clavicle,elbow,hand
• CT SCAN-presence of
pseudomeningocoele assoc. with nerve
root avulsions from spinal cord
• MRI SCAN-Brachial plexus visualised
directly;neuroma detected much more
readily
• EMG-NCV-limited role
-specific root damage cannot
be detected
-used as baseline invx for post-
op. f/u
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MANAGEMENT
• Repeated Clinical Evaluation-Reaction on
pinching, nail and hair growth, trophic
changes give an approximate indication about
sensations in the infant
• Clinical examination is repeated at 3 weeks
• splints used for maintaining external rotation
and abduction at shoulder are not particularly
helpful

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ROLE OF ELECTRO
PHYSIOLOGY
• Electromyography (EMG)
• Nerve conduction (NC) including CMAP and
SNAP
• Spinal evoked potentials (SEP)
• Somato sensory evoked potentials (SSEP)

 Progressively improving EMG with clinical

correlationconservative
 Denervation persists unchanged and SNAP
and SSEPpreganglionic injuryearly
operative intervention
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SURGICAL MANAGEMENT
• Initial reports of improvement in function following
surgical exploration of the plexus published in the
early 1900s
• Sever reported in 1925 and Jepson reported in 1930
disappointing results of surgeryconservative
approach secondary reconstruction viz.muscle
transfers,corrective osteotomies,or joint fusion
• INDICATIONS-
 Total palsy at birth with a positive Horner’s syndrome
 Upper root palsies with no sign of recovery at the
third month
 Upper root palsies with no sign of recovery of deltoid
or biceps at third month especially in those cases
where some recovery is present but not complete.
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SURGICAL TECHNIQUES
• Exploration of brachial plexus-clear ruptures,
avulsions of the entire plexus, avulsions of isolated
roots,neuroma
• Microsurgical repair-neurolysis, resection and
anastomosis;nerve grafting using sural nerves as
interposition grafts
 Common donor nerves-Spinal accessory (XIth)
nerve,Intercostal nerves (commonly 3rd to 6th),C4
motor root,Ansa hypoglossi, Opposite C7
 Common recipient nerves-Suprascapular,
Musculocutaneous,Axillary,Median nerves

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 • Actions to be restored in order of priority:
-Elbow flexion
-Shoulder stability (rotator cuff via suprascapular nerve)
-Shoulder abduction
-Hand prehension
 Results-
-Periodically evaluated post-op at three monthly intervals,
-signs of nerve regeneration like Tinel’s sign
-disappearance of trophic changes
-maintenance of muscle mass
-ultimate contraction and return of movement
-improvement in periodic EMG-NCV giving documentary proof
of nerve regeneration
Evaluation of results should be done using the Mallet scale of I-
IV grades or MRC grades for muscle power

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LATE OBSTETRIC PALSY
• Features unique to “Cross-innervation’ (caused by
misdirection of regenerated axons), muscular
imbalance and shoulder deformity due to growth,
mainly rotational or subluxatory.
• secondary operations to restore a more functional
muscle balance
 Episcopo procedure-transferring the Teres major and
Latissimus dorsi on the posterior side to the
infraspinatus and then on to the Humerus anteriorly
 Chuang procedure-transferring Teres major to the
Infraspinatus and the clavicular head of the Pectoralis
major to the area lateral to the long head of biceps
anteriorly
 Rotational osteotomy and capsulorraphy mainly for
internal rotation deformity and gross subluxation.
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THANK YOU

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